1194093708 NPI number — MRS. DANIELLE MARIE ANDERSON HERTAUS

Table of content: MRS. DANIELLE MARIE ANDERSON HERTAUS (NPI 1194093708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194093708 NPI number — MRS. DANIELLE MARIE ANDERSON HERTAUS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDERSON HERTAUS
Provider First Name:
DANIELLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ANDERSON
Provider Other First Name:
DANIELLE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194093708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11041 WISCONSIN AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPLIN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55316-3721
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-482-2477
Provider Business Mailing Address Fax Number:
763-424-4684

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11041 WISCONSIN AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPLIN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55316-3721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-482-2477
Provider Business Practice Location Address Fax Number:
763-424-4684
Provider Enumeration Date:
12/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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